21 January 2019

Exorbitant costs of routine medication repeats

WITH “standard costs” for dispensing prescription drugs again rising from 1 January 2019, it is time to cease an anomaly which increases costs and inconveniences patients without any health benefit.

The Pharmaceutical Benefits Scheme (PBS) requirement that dictates monthly medication dispensing for many long-term health conditions is an anachronism that needs to go. The evidence available favours longer prescription durations for selected chronic conditions for both health and financial outcomes. It is time to consider 3- or 6-month medication supply for many of these chronic diseases, and transfer savings from excessive pharmacy fees back to patients.

The monthly trip to the pharmacy for long term medication repeats is a well-known experience for many people. The inconvenience, the time, the travel, the script, the wait, the fees …. repeat medications are the unforgiving burden which make the community pharmacy a frequented establishment. It has been described by patients and carer’s as “the recurring hassle”.

Being on long-term medications is now the norm for many Australians. Medications for blood pressure, cholesterol, heartburn and first-line diabetes therapy are the majority of the top 10 drugs by prescription counts and drug quantity in Australia, and constitute a large percentage of drugs delivered to the community.

From a quality of care perspective, it is questionable whether the current standard monthly supply for chronic disease management is the best method to deliver medications efficiently and effectively. Is a 1-month supply of medication better than say, 3, 4 or 6 months, as is available for hypothyroid medication or the oral contraceptive pill?

Recent evidence reviews (here, and here) give consistent findings that there is very little support for monthly medication supply. Longer prescription lengths are associated with lower costs, better compliance and higher quality-adjusted life-years. Concerns that longer dispensed drug durations result in increased costs from medication waste also proved unfounded. Evidence that added waste occurred was inconsistent, and costs were more than offset by lower dispensing fees and time savings for both practitioners and patients.

With these medications, there is overwhelming evidence that medical supervision and treatment result in improved patient outcomes, but the rationale for lifelong pharmacist involvement every month is unclear. Currently, there is no evidence of clinical or other benefit from going to the pharmacy on a monthly basis to obtain these medications.

Increased drug supply is clearly not suitable for all chronic disease medications; antipsychotic agents, analgesics and other expensive drugs being examples; but for a sizable proportion of chronic disease management, longer prescribed medication supply is safe and appropriate. In Canada, maintenance drugs for long term conditions are encouraged and already being dispensed in 100-day supply. There is no reason Australia cannot adopt a similar policy.

With chronic disease medications topping the prescription counts in Australia, the savings to the health system in dispensing and administrative fees would be considerable. The opportunity to pass these savings on to patients should be undertaken, given serious cost problems now faced by patients for health care.

The main obstacle to this reform is pharmacy. Loss of revenue from prescription, administrative and handling fees would be significant. If you went to a chemist today and got 3 months’ supply of a drug, they can charge you three times the drug cost and three times the markup on the drug, plus three times the administration fees and three times the dispensing fees. Under the new proposal, they could charge three times the drug cost and markup, but only charge you once for the dispensing fee.

Pharmacy may well invent any number of reasons why this change should not be implemented, but the PBS was introduced for efficient and effective delivery of medications, not to sustain the business models of pharmacy. If two-thirds of medical visits were demonstrated to be unnecessary, there would be a major review and immediate change to clinical practice. Pharmacy should be no different.

In an efficient health system, the quantity and interval of repeat prescriptions should be evidence-based and should balance patient safety with clinical appropriateness and cost-effectiveness. This is not currently happening. The practice of routine monthly supply of medications simply increases costs and inconveniences patients without any health benefit. High prescription numbers place an unnecessary workload on pharmacists, which is associated with dispensing errors.

With health costs likely to be one of the major election issues, it is time to revisit reforms which decrease patient costs and improve outcomes. Addressing the costs of “routine” medication repeats and intervals should be a priority.

Dr Evan Ackermann is a GP on the Gold Coast. He has a long term interest in safety and quality issues, and is immediate past Chair of RACGP Expert Committee Quality Care. You can find him on Twitter @EvanAckermann

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.

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It is time to consider 3- or 6-month medication supply for many chronic disease medications

23 thoughts on “Exorbitant costs of routine medication repeats”

In addition to a longer supply period, how about modifying the number id diesel in a packet so that the tablets ” come out even”?
How many patients get confused, and miss out on one of their multiple medicines for a period because one drug runs out before the others?
Low dose aspirin comes in a packet of 112, blood pressure drugs in 30’s, othe r drugs in 28’s.
Many patients are elderly with declining cognition and experience difficulty managing this aspect of their treatment.
How about mandating that all medicines generally used for chronic conditions be standardised to a packet containing enough dose units for 12 weeks treatment at the standard dose?

Evan is right on the money – the only reason why this proposal wont suit pharmacists is that they lose dispensing fee income – ignore their shroud waving about waste or hoarding or patients at risk of overdoing or whatever. When a chronic disease drug is first commenced it is reasonable to give a limited quantity to ensure no toxicity, beneficial effects and patient adherence – but once these criteria have been met, then long term supply is no problem and benefits patients. And agree with Alex Hope that the quantities of drugs dispensed should be standardised for all long term chronic medications.

While you are reforming this can I suggest a standard system of drug branding and naming. Every generic has its own peculiar name which usually is displayed larger and bolder than the generic name. Pharmacies chop and change their suppliers etc so with monthly pick up, its likely the patient’s dispensed medication will change. Confusion to doctor and patient abounds . The generic name should be the name on the box , writ large and bold, across all brands and suppliers

Long overdue and should be pursued. Over the years life has become ever so busy and before one realises another month has gone by and then it is back to the pharmacy and the long wait to get the prescription filled.

I worked as a GP in NZ before coming to Australia. There, the standard prescription supply is 3 months for most medicines, and the copayment whether you are a concession holder or not is $5 for the whole supply. This is due to the combination of medication dispensing law and sensible bulk buying negotiations by the NZ equivalent of PBS, PHARMAC.
In 2013 the appalling costs to the Australian taxpayer were highlighted in the Grattan report, but both the then-labour health minister and subsequently the liberal one fobbed it off. As mentioned above, there is simply far too mich political influence of pharmacy on government, for all the wrong reasons. And of course there is not currently any political pressure to change since the current (poorly-designed) model is what the public are used to and expect. They resent paying to see the doctor but not the multiple very high copayments each month at the pharmacy, because that’s what people expect.

Another aspect of prescription is sometimes a visit to the doctor is only for purposes of getting a script. In patients with chronic conditions this can be arduous wait. In some countries, the patient can call up and the script is made available without the hassle of long wait at the GP clinic just for this purpose. Of course there is the potential loss of income for the GP

Patients question ‘useless’ visits to the doctor every 3-6 months for chronic conditions. Soon they will question ‘useless’ visits to the pharmacist every month. And so they should! I agree, three visits every month to the doctor for commencement of medication (to check for side effects etc), then every 3 months to pharmacist for chronic diseases. All tablets should expire the same day and be dispensed in their blister packs at the prescribed dose (to prevent patient confusion) and changes in trade names of generics should not be emphasised (to prevent patient confusion). Everyone is time-poor these days so ‘useless’ visits to the pharmacist should be encouraged or all pharmacies be linked to shopping centres where other things can be done during the 20 min or so wait for the pharmacist.

I would ask readers to look beyond the characteristic vindictive tone of the author toward the pharmacy profession and focus on the quality of material presented and the supporting references. Unfortunately, it is abysmal and does little to support his rhetoric (e.g. “A lack of good-quality evidence affected our decision modelling strategy…. the quality of the evidence was poor”; Miani et al). The author is, intentionally or otherwise, confusing dispensing of prescribed repeats with the writing of new prescriptions for each refill (prescription lengths vs. refill frequencies). Perusing the cited articles will indicate the “exorbitant” costs that the author so ferociously alludes to are primarily the costs of going to the GP monthly for a new prescription prior to dispensing (e.g. as per NHS model), not the dispensing of medication when a number of repeats have been prescribed (e.g. “Prescriber time costs accounted for the largest component of total unnecessary costs”; Doble et al.). The author appears to be conveniently blurring things here to pursue his relentless campaign against pharmacy. On the other hand, we are apparently meant to take for granted that there is “overwhelming evidence that medical supervision and treatment result in improved patient outcomes”. Does that also extend to generating repeat prescriptions and leaving them with the receptionist for patients to collect, for a fee? Let’s certainly hold the pharmacy profession (or at least some of its organisations) to account when warranted (e.g. the campaign against the re-scheduling of codeine to prescription-only), but the otherwise endless campaign by the author does become tiresome. To reduce healthcare costs, his time would be better spent working with pharmacists in educating consumers and tackling de-prescribing of drugs, such as the PPIs, one of the drug groups he is suggesting should be provided in larger quantities.

The purpose of this article is to decrease medication costs and management burden for patients without sacrificing quality of care. I am sure you would support these goals.

My article is directed at the PBS requirement which dictates monthly supply of medications for many chronic diseases. Ie I am not directing this at the pharmacy profession. It is a misinterpretation to infer that I am holding the pharmacy profession to account for this. I am not. Pharmacy is a financial beneficiary of this PBS requirement, as it is a source of resentment from patients because of it.

You are correct, the evidence is classified as low, due to lack of randomized controlled trials. Despite this, all studies favour longer term duration of dispensing. You have a prerogative to form a personal view that the article is an “endless campaign” with a “vindictive tone” to dismiss the argument; but that assessment falls flat on the fact that Canada has adopted longer dispensed drug duration’s for many drug classes associated with chronic disease. I put to you that this is a real issue, and a legitimate area for reform.

Your response raises the issue of repeat prescription writing. Under PBS rules patients can receive up to 6-months’ supply on prescription from a GP, which increases to 12-months’ supply if patients are on a chronic disease care plan. I doubt this is an over contributor to costs. The clog in the pipeline is the 1-month supply by pharmacy. I can understand an argument for monthly pharmacy involvement at the time of drug initiation – but not monthly involvement for life once on maintenance therapy.

Due to policy reforms, the costs of these medications are now so cheap, that the major factor in cost to patients is monthly dispensing fees. This is unnecessary cost and burden to patients who have a chronic illness.

Deprescribing is an issue I support, but that is another subject.

I welcome, as I am sure MJA Insight would welcome, considered responses from the Pharmacy profession on the evidence and rationale for amounts of drugs supplied by pharmacy under PBS rules. I put to you there is little consistency in rationale, and that is causing excessive costs and unnecessary burden of treatment for patients. This is an issue that should be addressed – and in my view – changed to 3 or 6 month supply for selected medications.

For pts who require a “staged supply” of a medication due to compliance problems-(i.e. pt otherwise consumes the medication too quickly) a barrier to “staged supply” is that the pharmacy charges a dispensing fee for each supply. For example, if the patient has a weekly “staged supply” dispensed of one week’s supply of the medicaiton at a time, from a total of 4 week’s supply. This adds up to four times greater dispensing cost per month for the patient, which the patient on a low fixed income says they cannot afford.

Regulation 24 (now regulation 49) has several requirements on the prescriber before being allowed. ie
The medical practitioner, midwife or nurse practitioner must first be satisfied all the following conditions apply:
• the maximum PBS quantity is insufficient for the patient’s treatment; AND
• the patient has a chronic illness or lives in a remote area where access to PBS supplies is limited; AND
• the patient would suffer great hardship trying to get the pharmaceutical benefit on separate occasions.
I am suggesting an alternative – longer term supply (eg 3 months) as routine maintenance therapy.

Further, according to PBS explanatory notes – For ‘Regulation 49’ PBS prescriptions, a pharmacist should charge the usual patient contribution for the original and for each repeat quantity needed to make up the equivalent of the total supply (plus any applicable special patient contribution, brand premium or therapeutic group premium, for the original and each repeat quantity in the total supply) ie multiple fees.

What is a Regulation 49 prescription?
Regulation 49 (previously referred to as regulation 24) means that, in certain circumstances, a PBS prescription can be written so that the quantities for the original and repeats are supplied at the same time. Regulation 49 was previously known as regulation 24.

A PBS Prescriber can write a prescription in this way if:
the single maximum quantity in the PBS listing is not sufficient for treatment of the condition;
and
you are using the medicine for treatment of a chronic illness or live in an area remote from the nearest pharmacy;
and
it would cause great hardship if you collected repeat supplies on separate occasions.
PBS prescriptions of this kind need to be endorsed with the words one supply or 1 supply (the words Regulation 24 or Reg 24 are also still valid for this purpose). RPBS prescriptions with the words hardship conditions apply. The patient charge that applies is a combined total equivalent to the patient payment or co‑payment amount that would otherwise apply for the original and each repeat making up the total supply. There may also be brand or therapeutic premiums charged for each quantity making up the total. The total patient payment or co‑payment amount eligible for Safety Net purposes (e.g., excluding premiums) can be recorded on your prescription record form (PRF) in the usual way.
Safety Net benefits for Regulation 49 prescriptions apply for the quantity as a whole. For medicines subject to early supply rules, Safety Net benefits apply for the total quantity if the interval between the Regulation 49 supply and the previous supply is greater than the specified period for the medicine. Safety Net benefits do not apply for the original or any repeats making up the total if a Regulation 49 supply is an early supply (within the specified period).
It is not necessary to have all repeats on a Regulation 49 prescription dispensed. However, any repeats not used when the prescription is supplied are forfeited.
For more information please visit the Regulation 49 sections under Prescribing Medicines, Supplying Medicines, and Patient Charges; and the Patient Contributions for Early supply of Some PBS Medicines section under Patient Charges.

Perhaps without throwing stones at other people’s houses would be more important with respect to Dr Evans’ article.
The general population enjoy going to a community pharmacy regularly – it may be one of their main reasons to venture out and holistically that is a positive point.

Realistically one cannot say the same about the client who gets a 3 minute consultation with their GP, obtains a prescription, a barrage of information they cannot digest and if they ask a question the response is generally “ Ask your Pharmacist” – next please! Hardly 21st Healthcare is it Evan? Be careful what you wish for and furthermore, the answer are generally within.
Don’t blame other for your (pl) failings – that could be deemed entitlement!

Re Anon. 23/1/19 @10:48am, He sets up a straw man and then knocks him down. Bravo. Actually, medical consultations tys dahese are otherwise than your description,which appears to be inspired by early televised comedy skit shows from Britain.

What an excellent idea!
We should also be able to get our repeats from the pharmacy, without having to waste government resources and our time at the doctors’ waiting room.
This will result in more people taking their medicines, as visiting the doctors just to collect scripts a waste of time.

Unfortunately the Pharmacy Guild are a very powerful lobby group and despite consumer organisations and GPs requesting the dispensing of 2 months supply of routine scripts at once it was rejected by the govt. The pharmacy Guild claims it is best for their customers to come into/ drive to their pharmacy monthly but it seems to me the only people who benefit from this costly exercise for customers ( in terms of time, money and the environment) are pharmacists. They routinely take 5 to 10 minutes to fill scripts even if there is no one else there, always giving you time to shop around and spend more money. I have decided to buy my medications on line from a reputable local on line pharmacy. It is much cheaper and I won’t need to shop around while I wait.